Total Wrist Fusion

What is Total Wrist Fusion?

Total wrist fusion, or wrist arthrodesis, is a surgical technique that involves permanently fusing the bones of the wrist joint to eliminate motion. During the procedure, the surfaces of the bones are prepared and brought together, allowing them to grow and fuse over time. This fusion eliminates movement at the wrist joint, providing stability and relieving pain caused by joint degeneration(arthritis) or trauma.

Who is Suitable for Total Wrist Fusion?

Total wrist fusion may be suitable for individuals who meet certain criteria. The decision to undergo this procedure is typically made after conservative treatments, such as medications, splints, and hand therapy, have failed to provide adequate relief. Suitable candidates for total wrist fusion may include:

• Individuals with severe arthritis in the wrist joint
• Those experiencing chronic wrist pain that significantly impacts their daily activities, work, or quality of life
• Patients who have undergone previous wrist surgeries, such as ligament repairs or joint reconstruction, without achieving satisfactory results
• Individuals with wrist instability, either due to ligamentous laxity or previous injuries
  

What are the Benefits of Total Wrist Fusion?

Total wrist fusion offers several benefits for individuals suffering from debilitating wrist conditions. These include:

• Pain Relief: By fusing the bones, the procedure eliminates the source of pain caused by degenerative conditions (arthritis) or trauma.
• Restored Stability: Total wrist fusion stabilises the joint by eliminating painful abnormal motion, restoring stability and improving functional abilities.
• Improved Functionality: By eliminating painful and unstable movement, individuals may experience improved grip strength, better load-bearing capacity, and enhanced hand function.
• Simplified Activities of Daily Living: Total wrist fusion allows individuals to perform activities of daily living more easily, reducing dependence on pain medications and adaptive devices.
• Predictable and Durable Outcome: Fusion provides a predictable and durable outcome as the fused bones gradually heal together, forming a solid union that can withstand daily stresses.

Types of Total Wrist Fusion

• Plate and Screw Fixation: This is the most common type of total wrist fusion. In this technique, a metal plate is fixed to the surfaces of the bones using screws, holding them in position during the healing process. The plate provides stability and allows for proper alignment of the bones during fusion.
• Intramedullary Rod Fixation: In this approach, a metal rod is inserted into the medullary canal of the radius bone (forearm bone), extending into the wrist's carpal bones and one of the hand metacarpal bones. The rod stabilises the joint and promotes fusion between the bones.
• External Fixation: External fixation involves using an external frame, typically metal rings connected by bars or rods, to stabilise the wrist during fusion. This technique may be used in complex cases or for individuals with poor bone quality.
• Arthroscopic Fusion: This is a minimally invasive approach where a small incision is made, and a specialised camera (arthroscope) and instruments are used to prepare the joint surfaces and insert bone grafts. This technique offers potential advantages such as smaller incisions and reduced soft tissue disruption.  Screws or a rod are used to hold the bones together while they fuse.

Alternative Options to Total Wrist Fusion

• Wrist Arthroscopy: In cases where the wrist condition is not severe or debilitating, wrist arthroscopy may be considered an alternative.
• Joint Resurfacing: This approach aims to repair or replace damaged joint surfaces, preserving wrist motion while addressing the underlying pathology.
• Partial Wrist Fusion: This procedure fuses only a portion of the wrist joint, preserving some degree of motion while providing stability and pain relief.
• Total Wrist Arthroplasty: Total wrist arthroplasty, or wrist joint replacement, may be considered for individuals with advanced wrist arthritis who desire preserved motion.

Preparations Before Total Wrist Fusion

• Before undergoing total wrist fusion, a thorough medical evaluation is essential. This includes a medical history review, physical examination and additional imaging tests, such as X-rays, CT or MRI scans, to assess the extent of the wrist condition and determine the suitability for surgery.
• Having a detailed discussion with the orthopaedic surgeon performing the procedure is crucial. This conversation should cover expectations, potential risks and complications, rehabilitation, and post-surgical care.
• Total wrist fusion restricts wrist motion, so it is important to consider lifestyle adjustments and potential limitations after the procedure. This may involve adapting certain activities or modifying work requirements to accommodate the fused wrist joint.

Total Wrist Fusion Procedure

• Anaesthesia: The procedure is typically performed under general anaesthesia, ensuring the patient remains unconscious and pain-free throughout the surgery. Regional anaesthesia, such as a nerve block, may be used to numb the forearm, wrist and hand.
• Incision and Joint Preparation: The surgeon makes an incision over the wrist, exposing the affected joint. The damaged cartilage is carefully removed from the joint surfaces, and the bones are prepared by removing any remaining cartilage and irregularities to promote fusion.
• Bone Fixation: The surgeon aligns the bones of the wrist joint in the desired position and stabilises them using fixation techniques, such as plates, screws, rods, or external fixators. These devices help maintain alignment and compression between the bones during healing.
• Bone Graft (Optional): In some cases, the bone graft material may be used to enhance fusion. The graft can either be obtained from the patient's own body (autograft) or a donor source (allograft) is placed between the joint surfaces to promote bone growth and fusion.
• Wound Closure and Recovery: The incision is closed using sutures once the bones are appropriately positioned and secured. The wrist is then placed in a splint or cast to protect the area and allow for proper healing. 

What to Expect After a Total Wrist Fusion?

The patient is closely monitored in the recovery area before being discharged with specific post-operative instructions. Here are some key aspects to expect after a total wrist fusion:

• Pain and Discomfort: Following surgery, it is common to experience some pain and discomfort around the surgical site.
• Immobilisation: To promote proper healing, the wrist will be immobilised using a splint, cast, or external fixation device. This immobilisation is essential for allowing the bones to fuse.
• Swelling and Bruising: Swelling and bruising around the wrist and hand are expected after surgery. 
• Restricted Wrist Motion: Total wrist fusion eliminates motion at the wrist joint. Therefore, you can expect a significant restriction in wrist movement. The forearm and fingers, however, should retain their normal range of motion.

Total Wrist Fusion Recovery Plan

• Follow Postoperative Instructions: It is crucial to adhere to your surgeon's postoperative instructions. This may include keeping the surgical site clean and dry, taking prescribed medications, and attending follow-up appointments.
• Immobilisation Period: The duration of immobilisation will depend on your surgeon's recommendations. During this time, it is important to protect the wrist and avoid activities that could disrupt the fusion process.
• Hand Therapy and Rehabilitation: Your surgeon will refer you to a hand therapist. This therapy will focus on managing swelling, gentle exercises, range-of-motion activities, and strengthening exercises for the forearm and hand.
• Gradual Return to Activities: Over time, you can gradually resume light activities and tasks that do not put excessive stress on the fused wrist joint. It is important to listen to your body and avoid activities that cause discomfort or pain.
• Long-term Follow-up: After the initial recovery period, you will still need regular follow-up appointments with your surgeon and hand therapist. These visits will monitor your progress, address concerns, and ensure the fusion is successful.

Total Wrist Fusion Prognosis

The prognosis after total wrist fusion is generally positive. While the wrist joint no longer moves, individuals can experience significant pain relief and improved stability. The fused wrist joint becomes solid over time, allowing for enhanced function and the ability to perform many daily activities.

It is important to note that each person's experience and outcomes can vary based on individual factors such as overall health, adherence to rehabilitation protocols, and the specific condition being treated.

Total Wrist Fusion Risks

• Infection: The surgical site may become infected, requiring antibiotics or additional treatments to address the infection.
• Nonunion or Malunion: In some cases, the bones may not properly fuse, resulting in nonunion or malunion. This can lead to persistent pain, reduced function, and the need for further intervention or revision surgery.
• Delayed Healing: Total wrist fusion relies on bone healing and fusion to achieve stability. Factors such as poor blood supply, smoking, and certain medical conditions can delay the healing process, prolonging recovery.
• Reduced Wrist Function: Total wrist fusion eliminates motion at the wrist joint, resulting in a significant loss of wrist function. While this can alleviate pain and improve stability, it does restrict certain activities and range of motion in the wrist.
• Adjacent Joint Stress: Following total wrist fusion, the adjacent joints, such as the elbow and fingers, may experience increased stress due to the loss of wrist mobility. This can lead to degenerative changes or overuse injuries in those joints over time.

What if Total Wrist Fusion is Delayed?

Delaying total wrist fusion can allow the underlying condition to worsen, potentially leading to further damage, prolonged pain, and impaired function. If you are experiencing debilitating wrist conditions that have not responded to conservative treatments, consult an orthopaedic surgeon to determine the appropriate timing for total wrist fusion and explore other options that may be available.